Cyberknife -- Problems with HMO -- Appeals

[fbarbera]

Hello All --

Quick insurance story with a happy ending.

I was treated with Cyberknife at Stanford in August 2007.  I was in an Aetna HMO plan based in Los Angeles at the time and the HMO rejected my claim every step of the way, based on their assessment that Gamma Knife (which was available in network) was just as good.  (Easy for them to say when it's not their hearing at stake.)  In any event, the final stage in the appeals process in California is to the California Department of Managed Care.  In support of that appeal, I drafted a letter explaining why CK is superior to GK.  Dr. Chang at Stanford also submitted a standard brief letter explaining the benefits of fractionated therapy and CK's accuracy.

Bottom line: the State of California overruled Aetna's determination, determined CK to be "medically necessary" in my case, and forced Aetna to pay for the treatment at Stanford.  So the lesson is:  appeal appeal and appeal.  I'll never know what impact my letter had and whether it made a difference but I think making my personal voice heard was important.

In any event, I am happy to provide a copy of my letter to anyone looking for a model.  Just email me at  frbarbera@yahoo.com.

Francesco

[Jim Scott]

Hi, Francesco:

Congratulations on your successful battle with your HMO!

Frankly, with the exorbitant cost of medical procedures and the steep cost of health insurance, fighting for a procedure to be covered by your insurer is really a necessity these days.  I'm delighted to see that you won your appeal, which you deserved to win.

Your story is encouraging and certainly does make it clear that we should never just 'give up' when an insurance company denies a claim. 

Thanks for sharing this information with us  - and I hope you're doing well in your recovery.

Jim